Evidence mapping of randomized clinical trials in hepatobiliary surgery

Evidence map of liver surgery: study protocol of a living systematic review

INTRODUCTION

The amount of scientific data on liver surgery is exploding. There is a critical unmet need to develop tools that will facilitate navigating the literature and offer easy, fast and accurate access to data with a high level of evidence. Evidence maps (EM) combining living systematic reviews (SR) and user-friendly synthesis with graphs and figures were developed for this purpose in other medical fields and showed promising results but remain yet unavailable in liver surgery. The present study protocol aims to generate an EM in liver surgery, gathering randomised clinical trials (RCT) and SR.

METHODS AND ANALYSIS

A systematic search will be conducted in the Cochrane Central Register of Controlled Trials, Web of Science, Embase and Medline to identify all RCT and SR concerning liver surgery. RCT and SR will be classified in research topics. Selected endpoints will be extracted and meta-analysed. Results will be freely available for patients, clinicians and researchers via a web-based evidence map platform. EM and meta-analyses (MA) will be updated at regular intervals.

ETHICS AND DISSEMINATION

Including publicly available data, this type of study design did not require ethical committee approval. EM displays the required properties to facilitate literature search and to get a rapid overview of the current evidence, an unavailable tool in liver surgery, to date. Generating such an aid may considerably help patients, clinicians and researchers in many aspects: accessing accurate data, helping in decision-making and identifying gaps in the field. On completion of the project, results will be published, freely available via www.evidencemap.surgery and permanently updated.

PROSPERO REGISTRATION NUMBER

CRD42023489201 (https://www.crd.york.ac.uk/prospero/).

Introducing and Validating the Multiphasic Evidential Decision-Making Matrix (MedMax) for Clinical Management in Patients with Intrahepatic Cholangiocarcinoma

Background: Despite the significant advancements of liver surgery in the last few decades, the survival rate of patients with liver and pancreatic cancers has improved by only 10% in 30 years. Precision medicine offers a patient-centered approach, which, when combined with machine learning, could enhance decision making and treatment outcomes in surgical management of ihCC. This study aims to develop a decision support model to optimize treatment strategies for patients with ihCC, a prevalent primary liver cancer. Methods: The decision support model, named MedMax, was developed using three data sources: studies retrieved through a systematic literature review, expert opinions from HPB surgeons, and data from ihCC patients treated at Heidelberg University Hospital. Expert opinions were collected via surveys, with factors rated on a Likert scale, while patient data were used to validate the model's accuracy. Results: The model is structured into four decision-making phases, assessing diagnosis, treatment modality, surgical approach, and prognosis. Prospectively, 44 patients with ihCC were included for internal primary validation of the model. MedMax could predict the appropriate treatment considering the resectability of the lesions in 100% of patients. Also, MedMax could predict a decent surgical approach in 77% of the patients. The model proved effective in making decisions regarding surgery and patient management, demonstrating its potential as a clinical decision support tool. Conclusions: MedMax offers a transparent, personalized approach to decision making in HPB surgery, particularly for ihCC patients. Initial results show high accuracy in treatment selection, and the model's flexibility allows for future expansion to other liver tumors and HPB surgeries. Further validation with larger patient cohorts is required to enhance its clinical utility.

Evaluation of quality and quantity of randomized controlled trials in hepatobiliary surgery: A scoping/mapping review

AIM

To evaluate the quantity and quality of randomized controlled trials (RCTs) in hepatobiliary surgery and for identifying gaps in current evidences.

METHODS

A systematic search was conducted in MEDLINE (via PubMed), Web of Science, and Cochrane Controlled Register of Trials (CENTRAL) for RCTs of hepatobiliary surgery published from inception until the end of 2023. The quality of each study was assessed using the Cochrane risk-of-bias (RoB) tool. The associations between risk of bias and the region and publication date were also assessed. Evidence mapping was performed to identify research gaps in the field.

RESULTS

The study included 1187 records. The number and proportion of published randomized controlled trials (RCTs) in hepatobiliary surgery increased over time, from 13 RCTs (.0005% of publications) in 1970-1979 to 201 RCTs (.003% of publications) in 2020-2023. There was a significant increase in the number of studies with a low risk of bias in RoB domains (p < .01). The proportion of RCTs with low risk of bias improved significantly after the introduction of CONSORT guidelines (p < .001). The evidence mapping revealed a significant research focus on major and minor hepatectomy and cholecystectomy. However, gaps were identified in liver cyst surgery and hepatobiliary vascular surgery. Additionally, there are gaps in the field of perioperative management and nutrition intervention.

CONCLUSION

The quantity and quality of RCTs in hepatobiliary surgery have increased over time, but there is still room for improvement. We have identified gaps in current research that can be addressed in future studies.